Pediatric obstructive sleep apnea

Pediatric obstructive sleep apnea syndrome : time to wake up

Veena Arali, Srinivas Namineni, Ch Sampath

IJCPD , JAN-APRIL 2012, 5 (1)

Introduction

“On Some Causes Backwardness

In Children”

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History

• OSAS – 1966

• PMC

• In 1976

11/22/2013 journal club 3Guilleminault et al jop

Obstructive Apnea: continued chest and abdominal motion in the absence of airflow during sleep

Obstructive Hypopnea: decreased airflow and alveolar ventilation in the presence of paradoxical motion of chest and abdomen

Apnea-Hypopnea Index: # of events/hour • Used to categorize severity of condition

• AHI > 1 abnormal, but clinically significant?

• Pathology in a snoring child not yet clearly defined


Definition

• OSAS in childhood, as defined by the American Thoracic

Society, is a disorder of breathing during sleep

characterized by prolonged partial upper airway

obstruction and/or intermittent complete obstruction,

obstructive apnea, that disrupts normal ventilation during

sleep and normal sleep patterns.


Epidemiology

• 8-12%

• 1-3%

• 5-6%


Physiology of breathing and sleep

• Upper air way resistance


Types of sleep

• There are five stages of sleep; four stages are considered non-REM sleep and one stage of REM sleep


What is REM sleep?

• Rapid eye movement..during a sleep period (eyes dart from right to left) stimulates occularmuscles;

• Called “active sleep” or “paradoxical sleep”;

• Respiration is irregular, heart rate is generally faster, blood pressure is higher…brain waves fast and shorter;

• Dreaming occurs;


EPIDEMIOLOGY

•


Pathophysiology


Pathophysiology

• Role of the Tonsils & Adenoids


Role of upper airway neuromotor tone

• Children with OSAS – ventilatory drive

• Neuromotor function- abnormal

• Accessory muscles- hypoxemia , hypercapnia


• Role of Arousal

• Role of structural factors

• Role of genetic factors


Clinical Symptoms

• Vary with the age



Clinical evaluation & diagnosis of

SDB1. The nose, one should look for asymmetry of the nares, a large

septal base, collapse of the nasal valves during inspiration, adeviated septum or enlargement of the inferior nasal turbinates.

2. The oropharynx should be examined for the position ofthe uvula in relation to the tongue.

3. The size of the tonsils should be compared with the sizeof the airway.

4. The presence of a high and narrow hard palate, overlapping incisors,a crossbite and an important overjet are indicative of a small jawand or abnormal maxilla-mandibular development


Objective confirmation of SDB

• Testing during sleeping –SDB

• Questionnaires

• Home monitoring

• Ambulatory monitoring

• Polysomnography


• Questionnaires Brouillette’s OSA questionnaire initially appeared

accurate in small sample, but on subsequent studies was indeterminate in 47%

» Brouillette, J Pediatr, 1984

Parents cannot predict severity of OSA based on their observations

» Preutthipan, Acta Paediatr, 2000


Home monitering

Audiotapes – lack specificity to distinguish OSAS from primary snoring.

» Lamm, Ped Pulm 1999

Videotapes

– sensitivity 94%, specificity 68%» Sivan, Eur Respir J, 1996


DiagnosisPSG

• Polysomnography = sleep study

• “Gold standard”

• Only technique that allows comprehensive monitoring of both cardiorespiratory function and sleep noninvasively


Polysomnography

• Polysomnography is the only test that may exclude the

diagnosis of SDB. It must always include monitoring of

sleep/wake states through electroencephalography (EEG),

electrooculography, chin and leg electromyography,

electrocardiography, body position and appropriate

monitoring of breathing.


• The American Thoracic Society has defined their criteria for an abnormal PSG in children as follows:

• Apnea index (AI) 1/hour

• Apnea-hypopnea index 5/hour

• Peak end-tidal carbon dioxide 53 mm Hg or

• An end-tidal carbon dioxide tension 50 mm Hg for 10% of the sleep period and

• A minimum hemoglobin oxygen saturation 92%.



Orofacial implications


• The most common orofacial characteristics encountered include

a retrognathic mandible,

narrow palate,

large neck circumference,

long soft palate (which leads to dentists’being unable to visualize the entire length of the uvula when the patient’s mouth is open wide), tonsillar hypertrophy,

nasal septal deviation

and relative macroglossia.


• The following features are found in OSA patients on a cephalogram:

An increased incidence of maxillary retrusion (ANB < 0)

An increased incidence of mandibular retrusion(ANB > 0)

An increased incidence of maxillary and mandibularretrusion (SNA and SNB)

The hyoid was more inferiorly and anteriorly placed

A thicker soft palate

A larger tongue; a longer pharyngeal length.


Treatment

• Adenotonsillectomy

• Medical therapies

Nasopharyngeal airway

Insufflations of pharynx during sleep

Continuous positive airway pressure via nasal mask

• Tracheostomy


• Pharmacological – Topical nasal steroids– Antibiotics– Nasal decongestant– Weight loss• Other surgical therapies– Craniofacial surgical procedures– Mandibular/maxillary plastic surgical procedures– Stenting procedures for nasal stenosis– Cleft palate revision procedures– Uvulopalatopharyngoplasty


Adenotonsillectomy

• Adenotonsillectomy is the most common treatment for childhood OSA

• Cure rate = 75-100%» Suen, Arch Otolaryngol Head and Neck Surg, 1995

• Complications– anesthetic

– post-op pain, poor oral intake and bleeding

– airway edema

– pulmonary edema


• 24 months of age

• OSA – 3wks of age

• Severe snoring & clinical symptoms- 6-24 months

• 6months of age.


Orthodontic treatment

• RMD

• SMD

• Rapid and slow maxillary distractions are performedbetween 5 and 11 years of age.

• Distraction results in widening of the palate and thenose; thus, these procedure remedies nasal occlusionrelated to a deviated septum, for which little can bedone before 14 to 16 years of age.


Oral appliances


Surgical treatment

• Surgeries, such as nasal septoplasty and othermaxillofacial surgeries, are indicated in some rare casesbut not usually seen in the pediatric population.

• Orthognathic surgery is normally postponed until 10 to13 years of age.

• Two surgical techniques used in patients with SDB are

mandibular distraction osteogenesis and maxillomandibular advancement


CPAP

Bilevel positive airway pressure11/22/2013 journal club 35

Sequelae of OSAS in Children

• Cardiopulmonary:

– Right ventricular hypertrophy

– Left ventricular hypertrophy

– Pulmonary hypertension

– Systemic hypertension

– Cor pumonale

– Polycythemia


• Neurodevelopmental:

– Developmental delay

– Hypersomnolence

– Poor school performance

– Leaning problems

– Hyperactivity

– Mood and behavior problems.


J. M. Battagel & P R. L'Estrange

• lateral cephalometric radiographs of 59 dentate, white, Caucasian males.

• 35patients with proven obstructive sleep apnoea (OSA) &

• 24 –conrol

• Radiograph traced

• conventional cephalometric measurements did not differ

11/22/2013 journal club 38European Journal of Orthodontics 18 (J996) 557-569

• significant reductions were found in the lengths of the mandibular body and cranial base and in cranial base angulation in OSA subjects.

• The combination of a short mandible and intermaxillary space, with an enlarged soft palate but decreased pharyngeal airway has relevance to the effective management of OSA.

• Inselected patients, advancement of the lower jaw by a nocturnal mandibular repositioning splint may be indicated.

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Wilhelmsson B et al

• To compare – dental appliance & uvulopalatopharyngoplasty for Rx of OSA

• RCT –UPPP or a dental appliance to achieve mandibular advancement of 50% of max protrusive capacity.

• Apnea Index (AI) Apnea & Hypoxia Index(AHI)

Oxygen Distraction Index(ODI) & Snoring Index(SI).

11/22/2013 journal club 40Acta oto laryngeal 1999; 119 : 503 -509

• Both groups show significant values of AI, AHI, ODI, & SI .

• dental appliance - adjunctive

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Conclusion


References

• A diagnostic approach to suspected obstructive sleep apnea in children journal of pediatrics Volume 105, Issue 1, July 1984, Pages 10–14.

• Can parents predict the severity of childhood obstructive sleep apnoea? Journal of acta pediatreciavol 89 ,issue 6 june 2000 ,708-712

• The cephalometric morphology of patients withobstructive sleep apnoea European Journal of

Orthodontics 18 (J996) 557-569


http://www.sciencedirect.com/science/journal/00223476/105/1

http://www.sciencedirect.com/science/journal/00223476/105/1


Technology

Pediatric obstructive sleep apnea